CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1106 1221.000000 45177.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1748 8386.000000 310227.5000 36.9935
Subtotal (Total Children Is Unduplicated) 1802 9607.000000 355404.5000 36.9943
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 86 87.500000 4375.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 112 111.250000 5562.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 10.500000 787.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 33 34.000000 2550.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 35.000000 1942.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 143 106.000000 7950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 160 119.500000 8962.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 330 378.500000 21006.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 200 196.500000 14957.8100 76.1212
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 34 34.000000 3963.6600 116.5782
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.000000 1263.8700 252.7740
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 6 6.000000 140.5200 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 561.5500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 34 34.000000 1735.7000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 19 19.000000 969.9500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 62 62.000000 3165.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 21 22.000000 1123.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 13 13.000000 663.6500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 13 13.000000 636.2200 48.9400
Subtotal (Total Children Is Unduplicated) 689 1315.250000 83520.0200 63.5013
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 51.750000 2587.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 77 2982.000000 74550.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1246 12902.00000 645100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1244 13417.00000 134170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 67 289.250000 20664.0200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 99 520.750000 29784.9800 57.1963
PHY-97110-PT SESSION BY LICENSED PT 69 400.750000 28408.1400 70.8874
PHY-97110HM-PT SESSION BY PT ASST 100 530.250000 30309.0900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 201.000000 14109.4000 70.1960
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 228.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 23 26.500000 367.8200 13.8800
Subtotal (Total Children Is Unduplicated) 1419 31325.25000 980279.7500 31.2936
-----------------------------------------------------------------------------------------------------------------------
Total 42247.500000 1419204.2700 33.5926
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1957
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 491 784.750000 28999.7500 37.0000
U 0 0.000000 0.0000 0.0000
B 767 1018.000000 40380.0000 0.0000
P 7588 20986.250000 470320.0500 460181.3900
D 18 21.500000 899.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 3021 11940.500000 608737.3700 260.0000
T 0 0.000000 0.0000 0.0000
5012 7350.000000 260319.7600 0.0000
Other 68 146.500000 9548.0900 30.0000
---------------------------------------------------------
Total 16965 42247.500000 1419204.2700 460508.3900